J Med Ethics: first published as 10.1136/jme.25.3.254 on 1 June 1999. Downloaded from Journal ofMedical Ethics 1999;25:254-258 Abandonment of terminally ill patients in the Byzantine era. An ancient tradition? John Lascaratos, Effie Poulakou-Rebelakou and Spyros Marketos National University ofAthens, National Centre ofHealth and National University ofAthens, respectively Abstract (anthropos) rather than to his art (techne) and to Our research on the texts of the Byzantine historians treat all his patients irrespective of class, status or and chroniclers revealed an apparently curious wealth and ability to pay. In these societies the phenomenon, namely, the abandonment of terminally doctors' altruistic duty apparently involves the ill emperors by their physicians when the latter compassionate care and consolation of the termi- realised that they could not offer anyfurther nally ill.3 For these reasons one can nowadays be treatment. This attitude tallies with the mentality of surprised to find, on studying the Byzantine histo- the ancient Greek physicians, who even in rians and chroniclers, some cases of abandonment Hippocratic times thought the treatment and care of ofdying emperors by their physicians who realised the terminally ill to be a challenge to nature and that they could not offer any further medical hubris to the gods. Nevertheless, it is a very curious treatment. The meaning of abandonment in these attitude in the light of the concepts of the Christian texts seems to have been exclusively restricted to Byzantine physicians who, according to the doctrines medical treatment when no further scientific help of the Christian religion, should have been imbued was possible and only philanthropic and Christian with the spirit ofphilanthropy and love for their compassion remained to be offered. As is self evi- fellowmen. The meticulous analysis of three examples dent, Byzantine medicine - basically philanthropic of abandonment ofByzantine emperors, and because it was a product of Christian philosophy - especially that ofAlexius I Comnenus, by their could not permit this custom of abandonment. physicians reveals that this custom,following ancient For this reason, these cases referred to by reliablehttp://jme.bmj.com/ pagan ethics, in those times took on a ritualisedform Byzantine writers appear at first sight unusual and without any significant or real content. inexplicable because they cannot be understood (7ournal ofMedical Ethics 1999;25:254-258) on the basis of the Christian thinking on and atti- Keywords: Byzantine care; caring ethics; terminally ill tudes towards the relationship between patients patients, tradition and physicians. On the contrary, in accordance with the way of thinking of Byzantine medicine, it would seem most rational for physicians to be in on October 1, 2021 by guest. Protected copyright. Introduction attendance on the patient and offer medical End-of-life decisions remain a complicated prob- assistance until the latter's death. Before, however, lem in the relationships between physicians and interpreting this curious custom, we should the patient's family, with social and legal conse- examine the cases which are referred to and quences which today face all civilised societies.' described by Byzantine writers. The attitude of doctors to euthanasia in particular seems to have occupied and troubled societies from antiquity, as the Hippocratic Oath and the The information provided by the concepts of the earlier Pythagorians indicate. Byzantine texts 1) A NEAR FATAL ILLNESS OF JUSTINIAN THE GREAT Although the Hippocratic Oath, perhaps following (527-565) the school of Pythagoras,2 is categorically against During the great epidemic which struck the every idea of euthanasia, it was thought unethical empire in the age of Justinian, the well-known for a doctor in ancient times to treat a patient with "Justinianic Plague",4 the emperor himself be- a deadly disease, for this challenged nature and came seriously ill. As evidenced by the historian constituted hubris against the gods, so the doctor Procopius: "The bubonic area of his body swelled would risk paying the penalty of divine nemesis. up".' The same contemporary historian notes in This concept is found even in some Hippocratic another of his works6 that: texts but cannot be justified in societies deeply influenced by the Christian religion where the "This epidemic struck the population of Byzan- physician ought to give love to his fellowman tium and it then happened that Justinian was seri- J Med Ethics: first published as 10.1136/jme.25.3.254 on 1 June 1999. Downloaded from Lascaratos, Poulakou-Rebelakou, Marketos 255 ously afflicted to the extent that a rumour was During the last stages of the emperor's disease, spread that he was dead". physicians made superhuman attempts to save him. At repeated medical councils his daughter, According to the historian, this rumour had the well-known historian Anna Comnena, who political implications because some were thinking had also studied medicine, presided. Comnena of the succession to the throne and this provoked provides us with the most valuable details of her the rage and immediate reaction of his wife, father's disease. In her text it is apparent that the Theodora, who after the unexpected recovery of dietetic therapy, the drugs, the phlebotomy, the the emperor punished harshly the would-be transfer of Alexius to the Maggana (another pretenders to the throne.7 More information is palace) for the change of air and finally the provided by Procopius in his third work,8 in which cauterisation of the stomach did not help the he writes: emperor but that, on the contrary, he remained on the verge of death. On the morning of 15 August "When Justinian fell seriously ill and gave the 1118: impression that he was about to die he had been abandoned by his physicians because he was con- "some physicians rubbed the head ofthe Emperor sidered to be already among the dead. Then the with myrrh and left for their homes, not because saints Cosmas and Damien appeared before him they had an urgent reason but because they knew and, paradoxically, saved him and his health was that fatal danger was approaching the Emperor". restored. The emperor, to express his gratitude, established a great and magnificent church in Comnena names three leading physicians among their honour at the end of the Golden Horn in those who had left, Nicholas Callicles, Michael Constantinople. Those who had lost all hope, as a Pantechnes and Michael the Eunuch. Comnena result of unsuccessful medical treatment by physi- also says that several hours later some physicians cians, took to the boats in the gulf and came to this returned to the emperor's bedside and checked his church, the only hope remaining for them." pulse, trying to encourage the empress, who was in a dreadful psychological state.'4 The abandonment of the emperor by his physi- Another contemporary chronicler, John cians when they realised the hopelessness of his Zonaras,'5 also refers to the last hours of the case is clearly evident from this extract. It must be emperor, writing that: http://jme.bmj.com/ pointed out that the physicians of the palace, the so called "actuarii", had the confidence of the "All day he was in death throes and in the emperor and his entourage. Furthermore, the afternoon he died at about seventy years of age dynamic Empress Theodora supervised and con- and his end was in complete contrast to his happy trolled the medical staff, as she did all other mem- reign, because he was abandoned by almost all his bers of the court and no Byzantine writer physicians and there were not even some to give suggested there was any hint of political motiva- him a final bath and to adorn his body in a way tion behind the physicians' act of abandonment. suitable for a king or even to provide him with the on October 1, 2021 by guest. Protected copyright. appropriate royal funeral." 2) THE FATAL DISEASE OF ALEXIUS I COMNENUS (1081-1118) These criticisms made by Zonaras must be On the question of the aetiology of the fatal carefully examined because he was prejudiced due disease ofAlexius I Comnenus many opinions and to a personal clash with Anna Comnena who had interpretations have been expressed. The first was removed him from the royal entourage'6 and he that ofVerdun, the Jesuit physician of H6tel Dieu, obviously wanted to apportion blame to her and Paris, who maintained that the emperor's death her brother, John, the heir to the throne, for failing was due to complications of sarcoma of the shoul- to look after their dying father. In any case, inde- der and thorax.9 This opinion was contradicted by pendently of Zonaras's interpretation, which Professor K Alexandrides who held the opinion scarcely hides accusations against Alexius's chil- that the emperor's disease was the result of heart dren, he also reveals that the emperor was failure due to a previous acute myocardial infarc- abandoned by his physicians. tion which manifested itself six months before his death while gout co-existed. It is known that 3) THE DISEASE OF ANDRONICUS III PALAEOLOGUS such heart attacks are frequent in this latter THE YOUNGER (1328-1341) condition because of sclerosis of the coronary In the last twenty years of his life Andronicus III arteries." This opinion became accepted by later presented crises of the enlargement of the spleen writers such as J K6rbler"2 and K-H Leven.'3 and febrile attacks. His disease, probably J Med Ethics: first published as 10.1136/jme.25.3.254 on 1 June 1999. Downloaded from 256 Abandonment of terminally ill patients in the Byzantine era. An ancient tradition? malaria,'7 caused the emperor to go into a coma and the tragedians maintain that "the son of and to die.